Citation Nr: 18152898 Decision Date: 11/27/18 Archive Date: 11/26/18 DOCKET NO. 16-48 491 DATE: November 27, 2018 ORDER A rating in excess of 70 percent for post-traumatic stress disorder (PTSD) is denied. FINDINGS OF FACT 1. The Veteran had active service from August 1985 to February 1987. 2. The Veteran was granted a temporary 100 percent rating for PTSD from November 17, 2014 to February 1, 2015. 3. For the remaining period on appeal, the Veteran had subjective complaints of anger, irritability, homicidal and suicidal thoughts without plans, poor concentration, anxiety, depression with hopelessness, hypervigilance, and sleep impairment; objective findings include a persistent danger of hurting self or others, orientation to person, place, time, and situation, good grooming and personal hygiene, memory ranging from mildly impaired to grossly intact, linear, goal-oriented thought processes, no hallucinations or delusions, speech at a normal rate, tone, and volume, and was able to communicate his needs. CONCLUSION OF LAW The criteria for a rating in excess of 70 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.71a, Diagnostic Code (DC) 9411 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSION As an initial matter, during the pendency of his appeal, the Veteran was awarded a temporary total rating beginning November 17, 2014 and ending February 1, 2015 for a period of hospitalization for his PTSD. 38 C.F.R. § 4.29. The following decision does not disturb that period granting him a temporary total rating. Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. Acquired psychiatric disorders, including PTSD, are evaluated under a General Rating Formula for Mental Disorders (“General Rating Formula”). Under the General Rating Formula, a 70 percent rating is warranted for occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, or mood, due to such symptoms as: suicidal ideation, obsessional rituals which interfere with routine activities, speech intermittently illogical, obscure, or irrelevant, near continuous panic or depression affecting the ability to function independently, appropriately, and effectively, impaired impulse control (such as an unprovoked irritability with periods of violence), spatial disorientation, neglect of personal appearance and hygiene, difficulty in adapting to stressful circumstances (including work or a work-like setting), and an inability to establish and maintain effective relationships. A 100 percent rating is warranted for total occupational and social impairment due to such symptoms as: gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, persistent danger of hurting self or others, an intermittent inability to perform activities of daily living (including maintaining minimum personal hygiene), disorientation to time or place, and memory loss for names of close relatives, own occupation, or own name. The symptoms listed under the rating criteria are meant to be examples of symptoms that would warrant the rating, but they are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). If the evidence shows that a veteran experiences symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the criteria for a particular rating, the appropriate equivalent rating will be assigned. Furthermore, the rating code requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment at a level consistent with the assigned rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). In a November 2012 treatment note, the Veteran reported that he was angry and had been angry for years. He described being assaulted while in active service and said that he still thought about seeking revenge against his assailants, but that he did not know who they were. He stated that he wished that he could find the commander who “brushed him under the rug” and kill him. He clarified that he would not follow through on his homicidal thoughts but that he was “that angry.” In subsequent treatment notes between November 2012 and April 2013, the Veteran reported prior instances of suicidal ideation, describing an incident where he put a knife to his wrist out of frustration. He denied current thoughts or plans. Clinicians noted that while his mood was depressed, his thought process was linear and goal-directed and he experienced no audiovisual hallucinations, delusions, preoccupations, obsessions, phobias, suspiciousness, or paranoia. The clinicians found that his short and remote memories were intact, that he was alert and oriented to person, place, time, and situation, and that he was able to communicate all of his needs. In multiple April 2013 doctors’ letters, private clinicians observed that the Veteran had severe anger, anxiety, difficult sleeping, lack of trust, nightmares, and a history of alcohol abuse, all stemming from an in-service sexual trauma. They noted that he lacked self-control and, when provoked, exhibited uncontrolled anger. They explained that he fantasized about wanting to kill those who hurt him. In a May 2013 VA examination, the Veteran described how he was assaulted while in-service and noted that he had received treatment for many years. The examiner diagnosed PTSD characterized by occupational and social impairment with reduced reliability and productivity. The examiner found that PTSD manifested in symptoms including irritability and outbursts of anger, difficulty concentrating, hypervigilance, suicidal ideations, disturbances of motivation and mood, a flattened affect, mild memory loss, a chronic sleep impairment, anxiety, a depressed mood, restlessness in sleep, night sweats, and isolation and withdrawal from others. The examiner ultimately opined that it was at least as likely as not that the Veteran’s PTSD was the result of his in-service stressors. In a July 2013 letter, a private clinician noted that the Veteran reported difficulty with anger control, communication, and a sense of being “used.” The clinician stated that he was unable to trust authority figures at work, became angry, “blew up,” and was fired on multiple occasions. The clinician described one incident where someone came up from behind him and touched the Veteran’s shoulder. In doing so, his anger was triggered and he grabbed and put the person up against a car. The clinician opined that the Veteran’s longstanding inability to maintain employment indicated a severe impulse control disorder. In treatment notes between July 2013 and December 2013, the Veteran complained of poor concentration, irritability with others, rage and aggressive episodes, anxiety, and constantly being on guard. While he noted mild subjective memory complaints, he said that he could remember assignments and keep schedules. He said that his attention was poor, and that he experienced depression with hopelessness, severe anxiety, and irritability symptoms. He reported fleeting passive suicidal and homicidal thinking, but denied acting on his thoughts and agreed to notify his doctors if he became suicidal. He said that he was able to maintain his personal hygiene but was unable to clean his home due to hip pain. Clinicians again found that he was oriented to person, place, time, and situation, that his speech had a normal rate and tone, that his thought process was clear, linear and goal-directed, that he was able to verbally communicate all of his needs, and that he did not demonstrate audiovisual hallucinations. In a December 2013 VA examination, the Veteran reported problems with anger and irritability, including “more confrontational stuff” such as road rage. He said that he only got 3 to 4 hours of sleep per night, that he was hypervigilant, felt on edge, and demonstrated an exaggerated startle response. The examiner diagnosed PTSD characterized by occupational and social impairment with reduced reliability and productivity. The examiner found that the Veteran exhibited PTSD symptoms including irritable behavior and angry outbursts typically expressed as verbal or physical aggression towards people or objects, hypervigilance, exaggerated startle response, concentration problems, depressed mood, anxiety, chronic sleep impairment, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. The examiner opined that the Veteran’s PTSD symptoms were not significantly more severe than they were in the May 2013 VA examination. In a July 2014 discharge summary, the clinician reported that the Veteran was hospitalized following homicidal ideations exhibited toward his neighbor. The clinician explained that the Veteran’s therapy dog was threatened for entering the neighbor’s garden and that, in response, he got a knife, cut down the garden, and subsequently surrendered his knives to a friend. He denied present homicidal ideations but said that he had chronic homicidal ideations for years, describing thoughts of killing his neighbors throughout the day and previously wanting to kill his two former wives and their husbands. The clinician stated that during the hospitalization, he did not show any signs of overt harm to himself or to others, that his thought process was linear and goal directed, he denied hallucinations, his memory was intact, and that he was oriented to person, place, time, and situation. In subsequent medical treatment notes between July 2014 and November 2015, the Veteran reported a history of attentional difficulties, including failing to pay attention to details, being easily distracted, forgetfulness, having difficulty following through on tasks, being inattentive during conversations, and exhibiting impulsive behaviors. He stated that he had no issues with hygiene, getting dressed, eating, and staying by himself for a few days. He reported having mild issues with taking care of his household responsibilities and tasks, getting them done timely, and doing them well. In a November 2015 VA examination, the Veteran noted that he had back pain that was so debilitating that he was unable to load and unload the dishwasher. He said that he laid in bed all day, denied any friendships, and that his girlfriend was “sick of him being sick.” The examiner diagnosed PTSD characterized by an occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and mood. The examiner found that PTSD symptoms included depressed mood, anxiety, suspiciousness, irritable behavior and angry outbursts, reckless and self-destructive behavior, chronic sleep impairment, mild memory loss, impaired judgment, disturbances of motivation and mood, difficulty establishing and maintaining effective work and social relationships, difficulty adapting to stressful circumstances, suicidal ideations and impaired impulse control. The examiner observed that the Veteran was pleasant, that he was appropriately dressed and groomed, and that his thought process was clear and linear. In a December 2016 VA examination, the Veteran reported continuing to experience flashbacks and nightmares of his assault, that he startled easily and was very hypervigilant. He said that his depression was “stronger than it [used to be],” that he continued to have panic attacks, and that he stayed at home and was paranoid of his new neighbors. He stated that he was unable to read because he could not concentrate, was not going out, and again carried knives due to his paranoia. The examiner found that the Veteran had PTSD symptoms including a depressed mood, anxiety, chronic sleep impairment, mild memory loss, flattened affect, impaired judgment, disturbances of motivation and mood, an inability to establish and maintain effective relationships, irritable behavior and angry outbursts, reckless or self-destructive behavior, and a persistent danger of hurting himself or others. The examiner noted that the Veteran was appropriately dressed and groomed, that his mood and affect were appropriate, that his thought processes were logical and goal-directed, and that he had no auditory, visual, or motor problems. Based on the above, a rating in excess of 70 percent is not warranted. While the medical evidence and December 2016 VA examination established that the Veteran has significant psychiatric symptomatology, medical treatment notes consistently found that his thought processes were linear and goal-oriented, his speech had a normal rate, tone, and volume, he was able to communicate his needs, he was oriented to person, place, time, and situation, and that he did not experience audiovisual hallucinations or delusions. Medical treatment notes additionally noted mild memory loss; however, he reported that he was able to keep schedules and remember appointments and the medical treatment notes found his remote and recent memory to be intact. Finally, the Veteran reported mild issues taking care of household responsibilities and tasks, including loading and unloading the dishwasher and cleaning the home. However, his hygiene was consistently good, he reported no issues getting dressed, eating, and staying by himself for a few days, and he attributed the difficulties he experienced performing activities of daily living to his back and hip pain rather than to his PTSD. Accordingly, the medical evidence does not support a rating in excess of 70 percent for PTSD. The Board has considered multiple statement offered by the Veteran, his family and his friends describing the severity of his PTSD. They are competent to report symptoms because this requires only personal knowledge as it comes to them through their senses. Layno v. Brown, 6 Vet. App. 465, 470 (1994). However, they are not competent to identify a specific level of disability of this disorder according to the appropriate diagnostic codes. Such competent evidence concerning the nature and extent of the Veteran’s PTSD has been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the VA examination and medical treatment notes) directly address the criteria under which his PTSD is evaluated. Moreover, as the clinicians have the requisite medical expertise to render medical opinions regarding the degree of impairment caused by the disability and had sufficient facts and data on which to base the conclusions, the Board affords the medical opinions great probative value. As such, these records are more probative than the subjective evidence of complaints of increased symptomatology provided by the Veteran, his family, and his friends, and the appeal is denied. Consideration has been given to assigning staged ratings. However, at no time during the periods in question has the disability warranted higher schedular ratings than those assigned. Hart v. Mansfeld, 21 Vet. App. 505 (2007). Finally, the Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record, for the Board’s consideration. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the record). L. HOWELL Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. Spigelman, Associate Counsel